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Safer Patient Care

Reflecting on CDI 2023 - Harnessing Momentum: A Turning Point for Clinical Documentation Improvement (CDI)

Mike Kertes September 19, 2023
As I sat on the plane on my return flight home from the Gold Coast, I couldn't help but feel a sense of pride and elation to be a part of something..

Clinical Documentation Improvement- a nursing role?

Joanna Forteath July 31, 2023
This article was first published in the Australian Nursing & Midwifery Journal (ANMJ) Jul-Sep Volume 28, No. 1 and has reproduced with consent. If I..

'What the Heck is This?' Written Documentation Queries: A Clinician's Perspective

Dr Felicity Sinclair-Ford May 26, 2023
What do we want? Clinicians who document efficiently and thoroughly, specifying diagnoses, linking them to interventions, and including pertinent..

A Week Back on the Wards

Dr Felicity Sinclair-Ford January 19, 2023
Dr Felicity Sinclair-Ford reflects on her recent time working clinically and how it illustrates potential challenges with clinician engagement.

A Tale as Old as Time: Heart Failure & Fluid Overload Part 2

Dr Felicity Sinclair-Ford December 13, 2022
In the last instalment, Dr Felicity Sinclair-Ford went on a quest to find all the coding standards and advice relevant to heart failure and fluid..

"Due To" Methylene Blue: A CDS Goes Down the Rabbit Hole

Cheryl Fenwick Evans December 2, 2022
Working as a CDS in the cardiovascular department, Cheryl Fenwick Evans saw a diagnosis she wasn't familiar with. Determined to know more, she dug a..

A Tale as Old as Time: Heart Failure & Fluid Overload

Dr Felicity Sinclair-Ford November 28, 2022
In a daring (yet pedantic) exploration, Dr Felicity Sinclair-Ford wants to dig deep into the coding rules around heart failure and fluid overload.

CDI: Documenting Diagnoses and Patient Safety

Cheryl Ericson July 29, 2022
Documenting a diagnosis in the health record extends beyond its impact on reimbursement and quality-of-care measures. It is also critical to patient..

What does clinical engagement look like in practice?

Qun Catherine Li July 19, 2022
The term of clinical engagement came to me very early in my safety and quality (S&Q) endeavour, my very first S&Q role almost 11 years ago. Two..

Our New Healthcare Heroes: The Next Generation of Clinical Documenters

Dr Felicity Sinclair-Ford February 11, 2022
It’s a frenetic time in Australian hospitals. After two years of COVID-19 suppression strategies, our borders, our country, and our lives, have..

I'm a CDS, Now What? - Transitioning into the CDS Role

Samantha Ryan October 25, 2021
Experienced Clinical Documentation Nurse Consultant Samantha Ryan reflects on the leap from clinical nurse to CDS.

Ignaz Semmelweis – An Unappreciated Visionary

Dr Felicity Sinclair-Ford September 29, 2021
To grow into the future, we can start by looking at the past. It’s an exciting time in medicine. Treatments and diagnostics that we could only dream..

CDS - Scope Creep

Dr David Tralaggan June 17, 2021
Are people in your hospital asking you to work beyond the scope of your clinical documentation specialist (CDS) role? You may be experiencing scope..

Junior doctors: paperwork lackeys or key allies for CDI? Part 2

Dr Felicity Sinclair-Ford June 4, 2021
Junior doctors occupy a unique and sometimes strange position within the hospital. We are doctors. We’re called when people are sick and..

Junior doctors: paperwork lackeys or key allies for CDI?

Dr Felicity Sinclair-Ford May 20, 2021
It’s 6:30am on the general surgical ward. Three residents are preparing for the round. We’re looking up results, printing lists, and creating ward..